Evidence Based Medicine:
Our treatment of heart attacks has come a long way since 1983, leading to spectacular improvements in survival. These advances are due to a standard for decision-making that is now deeply rooted throughout my world. That standard is known as “Evidence-Based Medicine.” Let me explain what I mean.
The first giant step forward in treatment of heart attacks was a research study published in 1988 that turned the medical world upside down. It was a randomized trial, our gold-standard for research. The study subjects were people who showed up in an emergency room with a heart attack. In these patients, the study was designed to measure the impact of two medications that could potentially open up a coronary obstruction: aspirin, which prevents blood clot formation, and streptokinase, the original “clot-buster” drug that can dissolve a clot after it forms.
The 17,000 subjects who were enrolled in the study were each randomly and secretly assigned to one of four treatment groups, basically through the flip of a coin. Group 1 was given aspirin and streptokinase. Group 2 received only streptokinase. Group 3 was given only aspirin – one tablet per day. Group 4 received neither – just usual care. By the clever use of placebos, or fake treatments, the researchers were able to disguise the real treatments, so that subjects could not tell what they were receiving. Nor could their physicians. So there was no opportunity for anyone to bias the results. No opportunity for fake news. To decide which treatment was better, the researchers compared mortality rates.
And the results were crystal clear. Among the completely untreated subjects, 13.2% died. Of those who received aspirin only, 10.7% died. Of those who received streptokinase only, 10.4% died. And of those who received both together, 8.0% died. So, aspirin and streptokinase were roughly equally effective as single agents, and even more so in combination.
Or to put it another way: if 100 patients with a heart attack were to receive both treatments together, only 8 patients would die instead of 13. That means 5 lives would be saved for every 100 patients treated. In relative terms, there would be 40% fewer deaths overall. That would be a stupendous advance in the treatment of heart attacks. In my world, this is what we call evidence. Pure information, free from bias.